Abstract
Infections caused by antibiotic-resistant bacteria results in high rates of morbidity and mortality. Although the prolonged cotrimoxazole (CTX) prophylaxis is arguably associated with the risk of increasing drug resistance in the common pathogens, information regarding its impact on Streptococci pneumoniae / pneumococcus is very limited. This study was conducted to investigate the effect of cotrimoxazole prophylaxis on nasopharyngeal colonization rate and antimicrobial resistance using Streptococci pneumoniae (pneumococcus) as an indicator organism among HIV patients in Arba Minch, Ethiopia. A comparative cross-sectional study was designed and conducted among HIV patients attending the Anti-Retroviral Treatment (ART) clinic of Arba Minch General Hospital (AMGH) from April 01 to August 31, 2018. A total of 252 participants were systematically selected and clustered into two study groups based on their CTX prophylaxis status, one taking CTX prophylaxis, and the second one, the control group (without prophylaxis). A structured questionnaire was used to collect socio-demographic and clinical data from patients. A nasopharyngeal swab was collected and cultured for pneumococcal isolation and identification in accordance with standard microbiological techniques. An antibiotics sensitivity test was performed according to the CLSI guidelines. Data were analyzed using the Statistical package for social science (SPSS) version 20. The primary outcome was determined using logistic regression analysis. Of the 252 enrolled HIV patients (mean age (37.38± 9.03 years), 144 (57.14%) were males. The overall, nasopharyngeal colonization rate of S. pneumoniae was 13.5% (95% CI: 8.4-15.6). Asymptomatic pneumococcal carriage rates among patients on CTX prophylaxis and the control group were 16.3%, and 10.3% respectively (p-value = 0.03). Regarding the risk factors analyzed, CTX prophylaxis (AOR: 2.2; 95% CI: 1.05-4.9) and gender (AOR: 2.5; 95% CI: 1.09-5.93) were significantly associated with pneumococcal colonization, showing a male preponderance. Cotrimoxazole-resistant pneumococci were 85.7% vs. 47.4% in the prophylaxis group and the control group respectively and it was statistically significant (AOR: 6.7; 95% CI: 1.3-36). Percentages of multi-drug resistant isolates in these two groups were 38.09 and 15.38 respectively (p-value = 0.04). Among the CTX resistant pneumococci isolates, 85% were also found to be co-resistant towards penicillin and was statistically significant. The percentage prevalence of nasopharyngeal pneumococci colonization was higher in patients taking CTX prophylaxis. It was noted that CTX prophylaxis eventually results in the selection of cotrimoxazole resistance and multi-drug resistance in pneumococci. There is evidence of existing cross-resistance between cotrimoxazole and penicillin antibiotics. Therefore, CTX prophylaxis must be administered judiciously. Surveillance for antimicrobial susceptibility is warranted where the prophylaxis is common.
Highlights
Cotrimoxazole prophylaxis is effective in reducing the morbidity and mortality in children and adults infected with Human Immunodeficiency Virus (HIV), its impact on the risk of increasing antimicrobial resistance remains a debatable public concern globally [1, 2]
A total of 252 subjects were enrolled and bifurcated, creating a pair of study arms: 126 HIV patients who have been on CTX prophylaxis, and 126 HIV patients who were not on CTX prophylaxis; age of the study subjects ranged from 16 to 67, the mean being 37.38± 9
Prevalence of nasopharyngeal pneumococcal colonization among HIV patients was 13.49% and this is in agreement with the findings of other studies undertaken in various parts of Africa
Summary
Cotrimoxazole prophylaxis is effective in reducing the morbidity and mortality in children and adults infected with Human Immunodeficiency Virus (HIV), its impact on the risk of increasing antimicrobial resistance remains a debatable public concern globally [1, 2]. Cotrimoxazole (CTX) is a broad-spectrum antibiotic co-formulation of trimethoprim and sulfamethoxazole (TMP-SMX), which inhibits the synthesis of bacterial tetrahydrofolic acid. It is used for the management of common bacterial infections and preventive prophylaxis against opportunistic infections among HIV patients [3]. The widespread CTX therapy upsets the patient’s micro-flora and results in the selection of resistant strains among commensals and pathogenic organisms at every ecological niche: patient, community, region, or country [10, 11]. The prolonged cotrimoxazole (CTX) prophylaxis is arguably associated with the risk of increasing drug resistance in the common pathogens, information regarding its impact on Streptococci pneumoniae / pneumococcus is very limited
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